& mes REMOTE STO 
i “Gr : 


Recent Progress in the Treatment 
of Epilepsy 


Read before the Steuben County Medical Society at 
Bath, N. Y., May 14th, 1907 


By 
WILLIAM P. SPRATLING, M. D. 


Medical Superintendent of the Craig Colony for Epileptics; Member, New 
York Academy of Medicine; Member, American Neurological 
Association; Member, American Medico Psychological 

Association; Permanent Editor, Transactions 
of the ‘Acsowalion for the Study of 
; Epilepsy, Etc. a oe TR 


Reprinted from Albany Medical Annals, February, 1908 


Reprinted from ALBANY MEpIcAL ANNALS, February, 1908 


RECENT PROGRESS IN THE TREATMENT OF 
ERIPERSY.. 


Read before the Steuben County Medical Society at Bath, N. Y., 
May 14th, 1907. 


By WILLIAM P. SPRATLING, M. D, 


Medical Superintendent of the Craig Colony for Epileptics; Member, New York Academy 
of Medicine; Member, American Neurological Association; Member, American Medico Psy- 
chological Association; Permanent, Editor, Transactions of the] Association for the Study 
of Epilepsy, etc. ct 

Although epilepsy is probably as old as the human race, its 
entire etiology remained a profound mystery until less than half 
a century ago when fragments of light began to appear and which 
are now sufficiently numerous to make our knowledge of the 
causes of “the strangest disease of human history’ more satis- 
factory than it has been since the public care of epileptics was 
first undertaken in 1867. In 1890 one state after another in 
the United States, following the lead of Ohio, began to make 
provision for epileptics who needed special forms of public care 
as much as do the insane, the deaf, the dumb, the crippled, the_ 
tubercular and the blind. 

Happily for the advancement of medical progress the time has 
gone when we may speak simply of “epilepsy.” The epileptolo- 
gist of to-day who would be accurate speaks of the “ epilepsies ” 
instead. 

We now know that epilepsy appears under as many forms, 
varieties, sub-varieties, types and divisions as it has causes; and 
that its causes are exceedingly numerous. 

Epilepsy is not a disease whose etiology can be traced to a 
single factor as we can do in typhoid fever and in tuberculosis; 
and so far as the laboratory has given us light in the study of 
the disease to this time, we know that sooner or later it affects 
certain areas of the brain in every case, and the.entire. brain. in 
some cases ; although the primary cause may lie in one part of 
the body i in one case, in another part of the body or in some special 
organ in another case, and in still another group of cases which 
comprise the greater majority of them all the cause is to be found 
only at intervals in the unstable tissues or secretions of the 


organism. In but few cases may the causes be due to a specific 
infection alone or to the action of a definite toxine originating 
in the digestive tract, but it may exist because of such toxines 
plus certain congenital cell conditions in the nervous system. 
In other words, epilepsy is an hereditary or developmental 
disease probably as often as it is a disease due to a specific 
agency or toxine of some kind, while the two combined are 
more apt to induce it than either acting alone. 

It has not been long since the epileptic was regarded with 
iat mysticism, superstition and ignorance and inhumanly 
itreated. Those who had it were charged with being “possessed 
of a demon.” This mysticism and ignorance still exists in some 
of the countries of the far East. Recently a celebrated American 
surgeon told me that when he stepped into the street in Constan- 
tinople to ascertain why a crowd that had gathered had sud- 
denly dispersed, it was because a man who was acting strangely 
had fallen in a fit and that for the natives to look upon such a 
victim was sure to bring “ evil luck.” 

) Nothing worthy the name of science was done for the epi- 
fret until 1849, when a small mixed asylum was founded near 
Bordeaux in France. ‘Twenty years later Bethel Colony at Biele- 
feld in North Germany was “founded—constituting the parent 
Colony for Epileptics, and which is the largest epileptic institu- 
tion in the world. There are many smaller institutions in Ger- 
many afid in England for the same purpose, a very admirable 
one being the Colony at Chalfont, St Peters, not far from London. 

; Seventeen years ago the movement for the humane care of 
boileptics crossed the Atlantic and was taken up by Ohio, which 
founded a hospital for sane and insane epileptics at Gallipolis. 
New York State followed next with The Craig Colony a 
Epileptics at Sonyea—which is still the only true “ Colony ” 
the United States—then Massachusetts, then’ New Jersey, en 
Texas, Pennsylvania and Indiana, and now several other States 
are on the point of granting aid to this class. But notwithstand- 
ing all this progress it is only a drop in the bucket, for out of 
a total of 150,000 to 160,000 epileptics in the United States less 


_» than 4,000 are at present under suitable care. What has been 


done for the insane should be repeated for the epileptic, and 
before another half century passes every State in the United 
States should have a colony, hospital or sanitarium for dependent 
epileptics. 


616.853 


Sp se REMOTE STORAGE 


EPILEPSY A COMMON DISEASE, 


ar ee a mistake to suppose epilepsy to be an uncommon disease. 
It differs so radically in its manifestations from all other diseases 
that many epileptics remain unrecognized for years. In some 
cases the attacks are so mild as to completely escape observation, 
or else they occur wholly by night and no one—not even the 
patient—be any the wiser, especially if urine is not voided, the 
tongue not bitten nor any unaccountable muscular soreness felt 
the next day to tell the tale of a nocturnal seizure. Morning 
headaches at intervals, a sore or lacerated tongue, a bad taste in 
the mouth, disturbed dreams, unexplained bruises or even 
fractures, should cause a suspicion of nocturnal epilepsy. A 
man of fifty-eight, syphilitic, awoke one morning to find that he 
had a fractured femur, and when it was later established that 
he was accustomed to nocturnal grand mal attacks it was thought 
that the fracture was due to muscular contraction, especially 
since there were no bruises and no fall so far as could be 


ascertained. 

[x has been estimated that one person in every five hundred is 
pileptic. | When I wrote “ Epilepsy and Its Treatment ” in 1904, 
I-was successful in securing statistical data relative to 67,000 


~cases of epilepsy running back to 1853, or a period of fifty-one 


years. I have studied the subject even more closely since then, 
and I am convinced that if all cases of epilepsy could be counted 
we would find not less than one epileptic to every three hun- 
dred of the population at large. I have time and again wit- 
nessed psychic epileptic seizures of so inconspicuous a character 
that an unskilled observer might absolutely fail to notice the 
presence of the seizure though he might be looking at the patient 
at the time. Such attacks are commonly known as “ flashes,” 
“darkness,” “ weaknesses,” “ faints,” “spells”? and the like; and 
they differ from ordinary Grand Mal and Petit Mal attacks in 
manifesting no muscular. commotion of any kind or degree what- 
ever. They are subjective rather than objective. Failure to 
recognize and count these as epileptic makes the apparent number 
of epileptics smaller. 


Tue Missinc LINK IN THE Stupy oF EPpILEPSY—PATHOLOGY. 


I am familiar with the work that has been done in epileptic 
pathology during the past fifteen years or so in this country and 


in Europe. A goodly number of skilled investigators have been 
active in this field. Some of them have asserted a defimite 
pathology in epilepsy. Prout and Clark in “ Epilepsy and Its 
Treatment” say: “ The most striking changes presented by the 
cortex of the epileptic are found in the cells of the second cor- 
tical layer—cells which are distinctly sensory in type. *In pa- 
tients dying during a period of status epilepticus these changes 
are most decided. The cells are swollen in many instances to 
twice their normal size, the nucleus being especially large and 
granular, with indistinct outline. The limitations of the nucleus 
are often difficult to determine. The most striking changes are 
found in the nucleus. In addition to being granular, swollen 
and poorly outlined, the nucleolus is often absent, having been 
abstracted from the nucleus in process of section making. This 
occurs in status cases two or three hundred times more frequently 
than in sections of the normal brain.” These same investigators 
say much more along the same line but the gist of the pathology 
of epilepsy, as they appear to conceive it, lies in the part quoted 
above. 

In the light of my experience in the study of some 4,000 
cases and the results of more than 250 autopsies made at The 
Craig Colony in twelve years, I doubt that this view of the 
pathology of epilepsy covers the problem in its entirety in all 
cases—or even in many cases. I am more willing to believe that 
the changes described by pathologists as having been found 
post mortem in brains of confirmed epileptics did not primarily 
exist as a cause of the epileptic seizures, but appeared later wholly 
as a result of such seizures. If that is true pathologists have 
mistaken results for causes. It is notable that the pathological 
conditions described above have never been found at the beginning 


of epilepsy, and if they are not present at the outset how could — 


they be the cause of the disease? 


PATHOLOGICAL WorK AT THE CRAIG COLoNny. 


In my judgment he who speaks of the “ Pathology of Epi- 
lepsy ’” would give expression to a more scientific phrase should 
he speak of the “ Chemical-pathology of Epilepsy,” provided he 
did not include cases due to gross organic lesions. Of late years 
we have re-organized the trend of laboratory work at The Craig 
Colony by turning aside from a wholly absorbing study of dead 


4 


eee 


matter from the post mortem table to a far more complex study 
of tissues, secretions and excretions from the living body, all 
studied conjointly with seizures during the epileptic’s life. It 
there be a pathological basis definable in cases of idiopathic 
epilepsy, I believe that chemistry combined with physiology dis- 
criminately employed during life will show it; and the scalpel, 
staining reagents, and the microscope are not competent to reveal 
it after death. 

Why will a strong, robust and seemingly healthy man go days, 
weeks, even months without a seizure and then begin to have 
headaches, become unaccountably irritable, desire to be let alone, 
become quarrelsome and faultfinding, face flushed, eyes bright, 
loquacious and finally unendurable to those about him, only to 
end this premonitory state that is so constantly repeated with 
an epileptic seizure or with a series of them? The auto-toxic 
process is repeated with similar results—self poisoning, the same 
subjective and objective symptoms, a fit, neutralization of the 
toxine— a normal period—and so on in rhythmic cycles until 
epileptic dementia is the end in some, cure in others, and no 
apparent change in the mentality of others. Let a patient of 
this type die in an attack—take his brain and remove that 
part of it that governs the area from whence the fits had their 
external origin—and what do you find? Nothing save a con- 
dition of cell vacuolation that as readily follows an ordinary well- 
marked normal fatigue. Now take the same individual just 
prior to the period when an attack is due to appear, and when 
the indications of a seizure daily grow in intensity until the fit 
neutralizes the epileptic virus—what should the proper chemical 
research reveal? It seems now that if we could find what tissues, 
secretions or excretions to search from the standpoint of the 
purely chemical pathologist, we should sooner or later find a 
definite poison whose presence in the system beyond the tolerat- 
mg point, is capable of creating the gravest epileptic phenomena. 
So at Sonyea we have become chemical pathologists instead of 
deadhouse pathologists only. But we do not decry the latter; 
we still make autopsies and a diligent search in every case for 
any organic condition capable of producing such phenomena. 

So far as I am aware the Colony at Sonyea is the only institu- 
tion in the United States that possesses the legal right to make 
an autopsy on the brain and spinal cord of every patient who 
dies there and who was supported at public expense; and I regard 


5 


these things—the study of living matter, tissues, secretions, the 
Anis aN life, its power, its changes, the organic life, its capacity 
to resist, its weak spots, so to speak; and the legal right to make 
an autopsy in so many epileptics—as two of the most promising 
steps in the study of epilepsy that have arisen in some years. 


THe PAssinc oF BROMISM. 


( \No greater reform in drug administration has ever taken place 
thin in the method of administering the bromide of potassium 
that under former methods of usage did more to injure the cure 
of epilepsy than can readily be imagined. ) I contend that the bro- 
mids have contributed nothing to the curability of epilepsy: If we 
accept the statements of such men as Nothnagel, Laehr, Acker- 
mann, Dana, Wildermuth, Habermas, Alt, Turner and others 
of equal opportunities we may be surprised to know that the 
percentage of cures in epilepsy is less to-day under free Bromism - 
than it was prior to 1857 when Laycock first used the drug in 
this disease. Some of the writers of seventy-five to one hundred 
years ago claim that thirty-eight to fifty per cent. of all epileptics 
could be cured; but the better classification of to-day, the sifting 
of false fits from the true, would doubtless reduce the higher 
figures of the remoter period to about what they are conceded 
to be to-day, viz., from seven and one-half to ten per cent. 

I have known scores of traumatic epileptics to take 120 to 160 
grains of bromid in twelve hours for years at a time. I have 
seen many scores of cases due to autointoxicants taking doses 
equally as large when a diametrically opposite form of treatment 
was indicated. 

I have seen scores of men and a few women whose epilepsy 
occurred between the fortieth and fiftieth years and due to “ food 
poisons” taking bromid in doses large enough to make food- 
poisoning doubly efficacious in causing convulsions when an 
opposite course of treatment was demanded—when reconstruc- 
tion and not destruction of nutrition was to be desired. Errors in 
metabolism will never be corrected by excessive bromid intoxi- 
cation. 

If the bromids are used at all do not give to exceed fifteen 
to twenty grains a day and increase to that amount so slowly 
that Bromism will not appear. It is unnecessary to cause bromic 
acne to get the physiologic effects of the drug. Five grains 


6 


7 
f 
y 


f 
/ 


three times a day given on Scientific principles are of far greater 
value than twenty grains three times a day given without due 
heed to eliminative precautions. 


CONTROL OF THE PATIENT IS ESSENTIAL IN TREATMENT. 


A point of great value in treating an epileptic is to be able to 
control his daily habits in all respects. This cannot be done by 
seeing the patient once a week or so at the office. You may 
lay down the most absolute and specific directions to certain 
patients but if you are not in a position to control all they do 
your directions are apt to go for nought. Some patients who 
have a real desire to get well will faithfully carry out every 
injunction you may lay upon them; but in my experience such 


persons are rare. 

[viens is essentially a disease of early life/ More than 
ghty-four per cent. of all cases occur before the age of twenty 

years and children are not endowed, with discretion, which makes 

it all the more essential that there should be a definite super- 

.vising power. It is well to remember that one indiscretion may. 


~undo all that has taken months to gain. Do not neglect to keep 


that fact before your patient’s mind. 


Another line along which progress has been made is that which 
has taught us that the epileptic is an unsatisfactory patient for 
office treatment alone, and that the nearer we control all he: does, 
what he eats, his sleeping, bathing, recreation—everything— 
the more likely will he be to experience an arrest of his attacks 


. or the absolute cure of his disease.” 


SURGERY. 


The use of surgery in the treatment of epilepsy has experienced 
great fluctuation; it is popular to-day and a year or two hence 
almost forgotten. Then one or two brilliant results will revive 
its employment. 

I believe surgery will enter upon a new era in the treatment 
of epilepsy after we have constructed a better classification of 
its forms based on a better knowledge of etiology. Why trephine 
a chronic epileptic with a marked neuropathic ancestry because 
the fits begin locally? Why trephine a traumatic epileptic fifteen 
or twenty years after the injury and after the patient’s mind has 
been destroyed? It is best to inquire carefully into the history 


7 


of the patient before opening the skull and to watch the attacks 
for two or three months, having a trained observer write out 
complete descriptions of as many as possible. At Sonyea if 
we deem an operation advisable we never perform it until three 
months later or until we can study the patient’s ancestry and 
the type and results of his fits in the uttermost detail. If there 
has been much mental impairment there is no use operating 
with a hope of cure, though amelioration might be obtained. A 
definite thing we have learned is that an operation performed 
this year may lead to an improvement so gradual that it may not 
become pronounced or cause a cure until several years. Do not 
look upon the operation as a means of immediate relief but as 
opening the way for cure or improvement some years later. 
In the meantime other forms of treatment should be vigorously 
kept up. 

Surgery in several anatomic localities is valuable in epilepsy; 
operations on the brain being the most common; next being pel- 
vic and abdominal operations in women and finally special opera- 
tions in either sex, such as the removal of the old cicatrices, 
cervical sympathectomony, and the like. Two out of three con- 
firmed epileptics under my care who were subjected to resection 
of the cervical sympatheis on both sides were cured. Not more 
than two or three per cent. of all epileptics are suitable for this 
operation. 

I might recite points to show the degree of progress made in 
late years in the treatment of a disease that in my judgment 
will have an increasingly hopeful prognosis as each year passes; 
but I will say only this: When we recall the recoveries in 
tuberculosis to-day, compared with the rate that pertained twenty- 
five years ago, there is ample reason to justify the belief that 
within twenty-five years epilepsy will be cured as frequently as 
insanity is cured now—that is, in twenty-five to thirty per cent. 
of all cases. I do not mean to imply any possible relationship 
between the genesis of epilepsy and that of tuberculosis. I only 
wish to invite a study of the remarkable change in the prognosis 
of tuberculosis—due to improved methods of treatment—and 
to point the way to the need for similar improvements in the 
treatment of epilepsy. 


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